PATIENT REGISTRATION AND MEDICAL HISTORY

-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐PATIENT REGISTRATION AND MEDICAL HISTORY-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐ Date______/_______/_______
Patients Name: ____________________________________ Single Married Divorced
Birth date ________________
Sex: M F
Cell Phone ___________________HomePhone____________________
E-Mail Address___________________________________
Street Address_______________________________ City ____________________State _____ Zip _______
Driver’s License # _________________________________
Patient Employed By______________________________________ Business Phone_______________
Spouse/Parent Name ___________________________ Spouse/Parent Birth date ___________
Spouse/Parent Employed by_______________________ Business Phone ____________________
Who is responsible for this account? _________________Relationship to Patient_______________
Patient Social Security #_________________________ Spouse/Parent:SocialSecurity#____________
Dental Insurance Company 1) __________ 2) __________ Group # _____________________
Phone ______________
Whom may we thank for referring you?_________________________________
-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐MEDICAL HISTORY-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐ Physician’s Name___________________________________ Date of Last physical__________
Have you ever had any of the following? (Check all that apply)
o
Diabetes
o
Respiratory Disease
o
Blood Disease
o
Heart Problems
o
Epilepsy
o
Arthritis
o
o
o
High Blood Pressure
Low Blood Pressure
Latex Allergy
o
o
o
Headaches
Hepatitis, Jaundice or Live Disease
General Allergies
o
o
o
Special Diet
Swollen Neck Glands
Hemophilia
o
Circulatory Problems
o
Cancer
o
Sinus Problems
o
o
o
o
Nervous Problems
Radiation Treatment
Artificial Heart Valves or Joints
Back Problems
o
o
o
Psychiatric Care
Chronic Diarrhea
Allergies to Anesthetics
o
o
o
o
A.I.D.S.
Stroke
Ulcer
Venereal Disease
o
Recent Weight Loss
o
Allergies to Medicines or Drugs
o
Chemical Dependency
Do you have any drug allergies or have you ever had an adverse reaction to any medication?
If so,what? ___________________________________________________________________________
Have you ever responded adversely to medical or dental treatment? _____________________________
Are you taking any mediation at this time? O Yes O No
If so what? _________________________________________
Are you currently under the care of a physician? O Yes O No
For what conditions?________________________
If patient is a child, what is his/her weight?_________Lbs.
(Women) Do you suspect that you are pregnant? O Yes O No Are You Nursing? O Yes O No
Is there anything else we should know about your medical history? ______________________________
_____________________________________________________________________________________
Total Smiles. LLC. 2014 -----------------------------------------------------------DENTAL HISTORY-------------------------------------------------------------Previous Dentist (if applicable) ______________________________________ City __________________
Date of last cleaning _______________ Date of last dental visit and reason____________________________
Is there any condition in your mouth that is causing you pain or discomfort? Yes No
If yes, what kind:_____________________________ ___________________________________
Do you do any of the following? (circle all that apply)
o
o
o
Bite cheeks or lips
Bite tongue
Clench teeth
o
o
o
Suck finger
Bite fingernails
Suck thumb
o
o
o
Breath through mouth
Tongue thrust
Notice frequent bad breath
o
o
o
Drink tea/coffee
Chew tobacco
Smoke
Are you satisfied with the appearance of your teeth? Yes No
What Can We Do For You Today? _________________________________________________________
THE ABOVE INFORMATION IS ACCURATE AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND IS ONLY FOR USE IN MY
TREATMENT, BILLING AND PROCESSING OF INSURANCE BENEFITS FOR WHICH I AM ENTITLED. I WILL NOT HOLD MY
DENTIST OR ANY MEMBER OF THE STAFF RESPONSIBLE FOR ANY ERRORS OR OMISSIONS THAT I HAVE MADE IN THE
COMPLETION OF THIS FORM.
Date:
/
/
Signature___________________________________
Assignment and Release
I, the undersigned, have insurance with ___________________________________________________________ and assign directly to Total
Smiles Providers, all benefits, if otherwise payable to me for services rendered. I understand that I am financially responsible for all
charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of
benefits. I authorize the use of this signature on all my insurance submissions whether manual or electronic.
Date: / /
Signature___________________________________
Minor/Child Consent
I being the parent of ____________________________________ do hereby request and authorize the dental staff to perform necessary
dental services for my child, including but not limited to x-rays, and administration of anesthetics which are deemed advisable by the
doctor, whether or not I am present at the actual appointment when the treatment is rendered.
Date:
/
/
Signature___________________________________
Financial Agreement By signing below I acknowledge the following: (1) I am responsible for any and all payment or co-‐payments for services rendered. (2) Any claims submitted to insurance which are subsequently declined shall become my responsibility. (3) In the event my owed balance should become delinquent, I acknowledge I may additionally become responsible for additional fees including but not limited to: late fees, collection fees, interest, court costs and attorney fees. Date:
/
Consent
/
Signature___________________________________
I consent to the diagnostic procedures and treatment by the dentist necessary for proper dental care. I consent to the
dentist’s use and disclosure of my records (or my child’s records) to carry out treatment, to obtain payment, and for those
activities and health care operations that are related to treatment or payment.
Date:
/
/
Signature___________________________________
Total Smiles. LLC. 2014

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PATIENT REGISTRATION AND MEDICAL HISTORY

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